certification application submission instructions...2018/03/25 · individual who holds a certified...

Georgia Addiction Counselors Association (GACA) Certification Committee

0.7-1-2010

Last Revised: 3-25-2018 EFFECTIVE 4-1-2019 - 1 - Application for CAC Certification

Certification Application Submission Instructions

It is the responsibility of the applicant to submit a complete application with all supporting documentation. Type or use computer

whenever possible; may be handwritten. If illegible or incomplete, your application will be returned without review and your

application fee will be forfeited. Appl icat ion fees are non -refundable. Applicant must meet minimum requirements for the

certification level to apply. If applying for CACI, but to seek CACII in the future, you will be given an opportunity to Upgrade to

CACII when minimum requirements are met for the higher level. Applications without the Application Fee will not be processed.

TO BE SENT BY APPLICANT DIRECTLY TO GACA:

Part I. Main Application and Application Fee

Complete the Entire Application in detail. Be sure to list your name as you would like it to appear on your certificate following successful completion of the certification process. See Fee Schedule for member and non-member rates.

Part II. Educational Training Verification Form Copy form as needed to list all educational hours.

Attach a copy of each training certificate to verify education provider, course, dates taken, and number of hours.

If academic hours from a college transcript are being used to satisfy education requirement, include these hours

(see below) on the Training and Academic Verification Form as well and include a copy of the transcript along with your

other training certificates. [An original transcript from the college/university must also be received by GACA directly

from the institution OR you may include an OFFICIAL transcript in UNOPENED envelope with your application.]

NOTE: In counting college transcript hours toward, remember to convert semester or quarter hours to the contact

hours/clock hours equivalent (see Certification Guidelines for conversion formula and maximum college hours allowed.)

TO BE SENT DIRECTLY TO GACA BY WORK SUPERVISOR, CCS, COLLEGE/UNIVERSITY/HS-GED OFFICIAL, AND

PROFESSIONAL REFERENCES:

Part III. Professional Letters of Reference

Two professional letters of reference required. One must be from a Georgia Certified Addiction Counselor (CAC). Letters

must state the applicant’s character and competency. Letters must be mailed directly to GACA by the professional

reference.

Part IV. Work Supervisor Evaluation Form Copy form as needed for multiple employers or positions

Form must be completed by each Supervisor for each job – including in the same agency or workplace–listed on the

application. This form must be completed by the work supervisor(s) and mailed directly to GACA by the supervisor.

Part V. CCS Supervised Practical Experience (SPE) Form Copy form as needed for multiple CCS’s.

This form must be mailed directly to GACA by the CCS completing the form. You must utilize the services of an

individual who holds a Certified Clinical Supervisor (CCS) certificate through GACA. See CCS List. The CCS must sign the

affidavit indicating that he/she believes your application to be complete and that you are appropriately prepared to

complete the certification process through written examination.

Part VI. Education Verification

An official college transcript OR official verification of High School Diploma or GED Equivalency (if highest educational

level completed) must be requested by the applicant to be sent directly to GACA to support all e d u c a t i o n a l

work [OR you may include an OFFICIAL transcript in UNOPENED envelope with your application]. Copies of college

transcripts submitted by the applicant are acceptable only as documentation to meet educational requirement (see

college hours limitations in guidelines to count hours.)


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General Instructions for Documentation

TO BE COMPLETED BY THE APPLICANT: Applicant must have met all minimum requirements of the level for which the application is submitted PRIOR to submission. CACI applicants who do not meet

the minimum requirements for CACII, but who may seek the CACII in the future, has an opportunity for Upgrade to CACII when all minimums have been met.

[See Certification Guidelines, Upgrade to CACII for details.]

A. Calculating Work Experience Hours

One year of full time paid employment at 40 hours a week, where 100% of the time is in counseling and counseling related

activities with addiction clients according to the above definition equals 2,000 hours of paid experience. If less than 40 hours a

week is worked, or if less than 100% of the employment time is in addiction-related counseling, that should be reflected on the

application. Volunteer time will only be considered if supervised by a GACA CCS. (SEE LIST OF CCS-CREDENTIALED COUNSELORS on

GACA website.)

Many professionals in many fields are associated with agencies which treat the chemically dependent person and many persons

in these agencies will have conversation with patients with some therapeutic intent. However, this experience or association

does not necessarily constitute chemical dependence/abuse counseling.

GACA has accepted the following definition of an addiction counselor: A person who by virtue of specialized knowledge, training

and experience is uniquely able to inform, motivate, guide, and assist those persons affected by problems related to chemical

dependence/abuse. Additionally, an addiction counselor conducts themselves in accordance to the GACA Code of Ethics. An

addiction counselor is an individual who has demonstrated the professional competency necessary to perform the tasks outlined

in the 8 counselor skill areas as espoused by NAADAC in providing chemical dependence treatment to clients and significant

others in a variety of treatment settings.

To be eligible for certification, an applicant must document work experience as a counselor of chemical dependence/abuse clients

according to the above definition. Paid experience or time when the applicant functioned as, for example, an aide whose duties

may include monitoring activities or attendance, etc., a nurse/doctor with medical responsibilities, an administrator with

supervising/management duties, marketing personnel, employee assistance, referral agent, telephone referral agent, etc., do

not constitute eligibility toward certification. It is the applicant’s responsibility to demonstrate that experience meets the criteria

for CAC eligibility.

B. Job Description Form

Complete a Job Description Form for each position (even with the same supervisor or agency) listed under Work Experience. It

must include each area listed on the Job Description Form (see examples).

C. Educational Clock Hours

Certified Addiction Counselor, Level I credentia l requires 180 clock hours of training/continuing education hours. A minimum

of 100 hours must have been taken within the last 5 years). A maximum of 90 of the clock hours for CAC Level I, if related to

counseling, may come from a college transcript (see below college hours conversion to contact/clock hours.)

Certified Addiction Counselor, Level II requires 270 clock hours of training/continuing education hours. A minimum of 160 hours

must have been taken within the last 5 years. A maximum of 135 of the clock hours for CAC Level II, if related to counseling, may

come from a college transcript (see below college hours conversion to contact/clock hours.)


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WORKSHEET FOR EVALUATING CERTIFICATION CLOCK HOURS

CAC I HRS CAC II HRS

GACA Providers (have a Provider Number and

be in-classroom, addiction-specific)

(Minimum 36 hrs) (Minimum 54 hrs)

NAADAC Providers (have a Provider Number ) (Not in GA) (Not in GA)

In-Service (Max Allowed 36 hrs) (Max Allowed 54 hrs)

Home Study / Internet (Max Allowed 18 hrs) (Max Allowed 27 hrs)

College (Max Allowed 90 hrs) (Max Allowed 135 hrs)

TOTAL (Minimum 180 hrs) (Minimum 270 hrs)

THE TOTAL HOURS MUST INCLUDE:

Training Contact Hours in past 5 yrs (Minimum 100 hrs) (Minimum 160 hrs)

Ethics (Minimum 6 hrs) (Minimum 6 hrs)

HIV/AIDS and other STD’s (Minimum 3 hrs) (Minimum 3 hrs)

Cultural Competency (Minimum 18 hrs) (Minimum 27 hrs)

Tele Counseling (or equivalent, i.e.:

E-Therapy, E-Counseling, Telemental

Health)

(Minimum 6 hrs) (Minimum 6 hrs)

EXPLANATION OF EDUCATIONAL CLOCK HOURS:

Basic Skills Courses – Each candidate should be well educated in the basic counselor skills. Courses should cover basic

counseling knowledge and skills as outlined in the CERTIFICATION GUIDELINES, NAADAC SCOPE OF PRACTICE.

1. GACA Providers - All education hours for certification or recertification in this category must have GACA provider

number, current at the time of the course completion, printed on the certificate to meet this requirement.

2. NAADAC Providers/Approved Providers – other counseling related training hours. NAADAC provider number must be

printed on the certificate.

3. In-service – Training/education hours required by employers to keep employees current may be counted toward

certification/recertification. In-service time must be appropriately documented as to date, subject, time involved, and

individual’s name that provided the in-service. If hours are kept by the employer in a compiled listing, the staff

member responsible for giving credit for the in-service may sign this sheet. These hours must be documented as “In-

service”.

a.) These hours must be directly related to counseling skills and/or knowledge needed to keep up to date in the field of

addiction. (Defensive driving, CPR, hand-washing techniques, etc. cannot be counted as in-service

hours for certification.)

b.) Group therapy/seminars in which the applicant participated while in treatment at a facility cannot be

counted for certification.

c.) Films and video tapes counted as in-service must have documentation from program director/education director that

viewing was supervised, and content discussed with supervisor.


0.7-1-2010


4. College Courses – Must be in subjects that have specific relevance to the field of counseling and/or addiction. (Core

courses such as English, Science and Math cannot be counted for certification.)

a.) One (1) semester hour equals fifteen (15) clock hours. One (1) quarter hour equals ten (10) clock hours. One (1)

trimester hour equals five (5) clock hours.

b.) An official transcript noting course date, grade, and credit hours earned is required when using college course for clock

hours credit. The official transcript must be mailed directly to GACA or included with the application in a sealed

envelope directly from the college or university.

c.) The college must be accredited and listed on the Council for Higher Education Accreditation web site. (www.chea.org)

5. Continuing education must be sponsored by an organization, group or individual recognized as knowledgeable in the field of

chemical dependence/abuse. A CEU is not the same as contact/clock hours. The value is 1:10.

a.) Courses must be specifically relevant to chemical dependency/abuse

b.) One (1) C.E.U. equals ten (10) clock hours (Example: .6 CEU’s is equal to 6.0 clock/contact hours)

6. Ethics Education – Six (6) hours of ethics education must be documented. GACA has determined that the following areas

should be m i n i m a l l y covered in the six hours o f education: legal issues, c lient welfare, professional competence,

development, supervision, therapeutic boundaries, financial issues, personal wellness, conduct relationship to other

counselors and code of ethics, etc.

7. HIV/AIDS and other STD’s Education – Three (3) hours of HIV/AIDS and other STD’s education must be documented.

8. Cultural Competency – At least 18 clock hours for CACI and 27 clock hours for CACII of the required education hours must

be related to the development of cultural competency. This should be training in areas such as: People of Color, Women,

Adolescents, Geriatric, Gay/Lesbian, Physically Challenged, Cultural Diversity, Criminal Justice, religion, veterans, or other

special populations as they are challenged by substance abuse.

9. Tele Counseling – Six (6) hours of education in Tele Counseling or other equivalent training such as Telemental Health, E-

Counseling, or E-Therapy must be documented.

D. Work Supervisor Evaluation Form

Applicant must receive a minimum of 96 hours of supervision by a GACA CCS to be eligible for a CACI, and the remaining 124 hours

of supervision by an approved work supervisor for a total of 220 hours. Applicant must receive a minimum of 144 hours of

supervision by a GACA CCS to be eligible for a CACII, and the remaining 76 hours of supervision by an approved work supervisor for

a total of 220 hours. An approved work supervisor is certified or licensed with at least one of the following credentials: NCACI,

CACII, NCACII, CADCII, CAADC, LCSW, LMFT, LPC, RN, APN, Addictionologist, Psychologist, Psychiatrist or other licensed behavioral

health providers.

On the Work Supervisor Evaluation Form, the work supervisor is asked to document only that experience which qualifies as

chemical dependence/abuse counseling according to the GACA requirements and definition. Volunteer work must be documented

on the Work Supervisor Evaluation Form in the same manner as any other paid work supervisor.

A separate work supervisor evaluation form is required for each position held (even if with the same supervisor or agency). The

supervisor must document the applicant’s experience in the 8 counselor skill groups. Only experience in which the applicant

functioned as a counselor/therapist should be documented as opposed to an aide or attendant whose function is one mainly of

monitoring activity, attendance, etc.

http://www.chea.org/


0.7-1-2010


E. Certified Clinical Supervisor (CCS) Supervised Practical Experience Form

Applicant must receive a minimum of 96 hours of clinical supervision by a GACA CCS to be eligible for a CACI, and the remaining 124

hours of supervision by an approved work supervisor for a total of 220 hours. Applicant must receive a minimum of 144 hours of

clinical supervision by a GACA CCS to be eligible for a CACII, and the remaining 76 hours of supervision by an approved work

supervisor for a total of 220 hours.

Supervised Practical Experience (SPE) must be done by a GACA Certified Clinical Supervisor (CCS) and is supervision which teaches

chemical dependence/abuse counseling. This experience may be academic, as in practicum, or may be a part of eligible work

experience. The supervision must include one-on-one and group. The fact that an applicant worked under administrative

supervision does not in itself satisfy this requirement. The reporting function is to be distinguished from the learning function.

Thus, attendance as pa r t of continuing education training or attendance at staff meetings to report on client progress may not

be considered supervision. The supervision should include activities designed to provide education in specific skill groups and be

monitored by a CCS who provides timely positive and negative feedback to assist in the development of supervised knowledge

and competence. A minimum of 220 hours of supervision is required.

On the SPE form, the supervisor will indicate the amount of time and type of supervision, including only the time spent in

supervision – not the time spent performing the skill. Only the person who does the actual supervision may sign the form. The

SPE form should be mailed directly to the GACA office by the CCS. If you have any questions, please call the GACA office.

F. Guidelines for Professional Letters of Reference

Two letters of reference, one of which must be from a GACA certified counselor, that refer to your professional qualifications may

be forwarded directly to the GACA office by the reference. In some instances, for expediency, the letters may be included with the

application package provided they are sealed in individual envelopes by the writers who will also initial the flaps in two places.

Letters from relatives are not acceptable.


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Fees for Service All Fees are Non-Refundable

GACA/NAADAC

Member

Non-Member

CAC Initial Application

Certified Addiction Counselor CACI / CACII Application Submission 150.00 300.00

Written Examination (Do not pay until notified of application approval) 150.00 150.00

Total Fees for Initial CACI / CACII Certification Fees are payable at time of each individual service

300.00 450.00

Become a Member or Renew Membership

Professional Level Member (For applicants who are licensed or certified.) 145.00

Associate Level Member (For applicants who are not licensed or

certified.)

124.00

Student / Military / Retired (See GACA Website for qualifications.) 62.50

Retest / Resubmission for CACI / CACII

Written Examination - Retest 150.00 150.00

CCS Initial Application

Certified Clinical Supervisor (CCS) 125.00 175.00

CCS Written Examination (Do not pay until notified of approval) 200.00 200.00

Total Fees for Initial CCS Certification Fees are payable at time of each individual service

325.00 375.00

Retest for CCS

Written Examination - Retest 200.00 200.00

TOTAL AMOUNT DUE

Make check or money order payable to

Georgia Addiction Counselors Association

$

$

COMPLETE BELOW FOR CREDIT/DEBIT CARD PAYMENT

I hereby authorized GACA to charge the above total amount to the following account:

Acct# - - -

Expiration Date on Card / VIN# (last 3 digits on back of card)

X

(cardholder signature) (Company, If Applicable)

Print name as it appears on card)

Cardholder Billing Address: Street:

City, State ZIP (Zip Code Required to Process Credit Card)

RELATIONSHIP TO APPLICANT, IF NOT APPLICANT


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CERTIFICATION APPLICATION FOR

ADDICTION COUNSELING PROFESSIONALS

Certification applied for (select one): CERTIFIFIED ADDICTION COUNSELOR: CAC I

CERTIFIFIED ADDICTION COUNSELOR: CAC II

Name:

Last First Middle Maiden

Address:

Street or PO Box City County State Zip

Daytime Phone: Cell Phone E-mail:

Date of Birth: Social Security No: (last 4 digits)

(for statistical purposes only)

GENDER: _Male Female Race

MARITAL STATUS: Single Married Separated Divorced Widowed

LEGAL STATUS Applicant must be cleared of all criminal charges / misdemeanors and/or felonies, and probation and/or parole requirements prior to applying for certification. All individuals who have a prior criminal record with felony convictions / charges will be required to submit a Criminal Background report to the Certification Committee. If an applicant is still on probation the following must be provided. For a period of 2 years prior to the application: 1) Evidence of no new charges, and 2) Evidence of compliance with all probation requirements and conditions.

Have you ever been arrested, charged and/or convicted of any felony?

Do you have any pending felony charges?

Yes No Yes No

If YES to EITHER QUESTION, please explain and give present status of charge; include a criminal background check.

INSTRUCTIONS Provide detailed information for all sections of this application. Print legibly or type. Incomplete or unsigned applications will be

returned to applicants for completion, causing delay or disqualification. Applications without payment will not be processed. A

resume may be attached but will not be accepted as a substitute for a completed application form.


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AFFIRMATION OF CODE OF ETHICS

On October 15, 2017, Georgia Addiction Counselors Association (GACA) adopted the NAADAC/NCC AP Code of Ethics that was updated and became effective October 9, 2016. The Code of Ethics sets nine principles that consider the clinician, supervisor, and relevant others. The nine principles are: Principle I: The Counseling Relationship Principle II: Confidentiality and Privileged Communication Principle III: Professional Responsibilities and Workplace Standards Principle IV: Working in a Culturally-Diverse World Principle V: Assessment, Evaluation and Interpretation Principle VI: E-Therapy, E-Supervision and Social Media Principle VII: Supervision and Consultation Principle VIII: Resolving Ethical Concerns Principle IX: Publication and Communications The GACA Code of Ethics provides direction and guidance to addiction counselors, education providers, service organizations, regulatory boards, legislators, and other related parties. The GACA Code of Ethics is located at http://gaca.org/about-gaca/gaca-code-ethics/. Ethics code violations may result in disciplinary actions, including loss of credential. I HEREBY AFFIRM that I have read and understand the entire GACA Code of Ethics and all nine principles stated therein. I subscribe to and commit myself to professional conduct in keeping with the Code of Ethics of GACA.

Applicant’s Signature Date Signed

________________________________________________

Applicant’s Name Printed

http://gaca.org/about-gaca/gaca-code-ethics/


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OATHS

I HEREBY CERTIFY THAT ALL OF THE INFORMATION GIVEN HEREIN IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I ALSO AUTHORIZE ANY NECESSARY INVESTIGATIONS AND THE RELEASE OF MANUSCRIPTS AND OTHER PERSONAL INFORMATION

RELATIVE T O M Y C E R T I F I C A T I O N . (FALSIFICATION WILL NULIFY THIS APPLICATION AND MAY RESULT IN

REVOCATION OF CERTIFIATION.)

(Signature) (Date Signed)

ASSURANCES AND RELEASE

PLEASE NOTE: GACA reserves the right to request further information from all employers and other persons listed on the

application form. The Certification Board and its review committees reserve the option of requesting an oral interview with the

applicant. This information will be strictly used to evaluate the professional competence of the applicant as requested in order to

verify education, employment, etc. This information is not available to anyone outside this process without the written consent of

the applicant.

“I give my permission for GACA and its staff to investigate my background as it relates to statements contained in this

Application for Certification. All of the information given herein is true and complete to the best of my knowledge and belief. I

understand that intentional false or misleading statements or intentional omissions shall result in denial or revocation of

certification.”

“I consent to the release of information contained in my application file and other pertinent data submitted to or collected by

GACA to officers, members, and staff of the aforementioned Board.”

“I further agree to hold GACA, its officers, board members, employees and examiners free from any civil liability for damages or

complaints by reason of any action that is within the scope of the performance of their duties which they may take in connection

with application and subsequent examinations, and/or the failure of GACA to issue certifications.”

“By affixing my signature below, I certify my complete understanding of these statements and my intention to be fully bound

thereby.”

(Signature) (Date Signed)

Completed Application to include Application Fee of $150.00 for NAADAC/GACA members or $300.00 for non-

members and copies of supporting training certificates and other documentation should be mailed to the

address below.

Forms completed by the Work Supervisor and CCS; professional reference letters, and original college

transcript or High School/GED verification, must be mailed D IR E C T L Y to GACA by these individuals and/or

agencies except as noted in instructions. Do not fax or e-mail this application or supporting documentation.

Georgia Addiction Counselors Association

4015 South Cobb Drive, Suite 160

Smyrna, Georgia 30080

EDUCATION:

An official college transcript OR official verification of High School Diploma or GED Equivalency (if highest educational level

completed) must be requested by the applicant to be sent directly to GACA to support all educational work, OR you may include

an OFFICIAL transcript in an UNOPENED envelope with your application. Copies of transcripts submitted by the applicant are not

acceptable except as documentation to meet educational requirement (see college hours limitations in guidelines to count hours).

WORK EXPERIENCE: Rather than request a complete work history, list your present employment, then from your past employment select only those

work experiences which fit the description of qualifying experience. Refer to Certification Guidelines for details. The

Certification Board will contact you or your supervisor(s) if additional information is needed to determine acceptability of your

work experience.

Provide a BRIEF job description for each position (even with the same supervisor or agency). An agency/workplace Job

Description may be attached i f necessary to further document your addiction counseling experience. See Certification Guidelines

for specifics.

Most Recent Employer Name of Employer:

Mailing Address of Employer: Telephone - include area code and/or extension:

Your Job Title: Dates of Employment for this position:

( month - year ) to ( month - Year )

Name and Title of Immediate Supervisor: Number of Hours per Week:

Primary Job Duties:

Georgia Addiction Counselors Association (GACA) Certification Board

O.7-1-.2010 Application for CAC Certification

Last Revised: 3-25-2018 EFFECTIVE 4-1-2019

- 9 -

Name & Location

Dates

Attended

Completed

Yes/No

Degree Received

(Diploma, Associate, BA,

BS, MA, MS, PhD, etc)

High

School/GED

College

Post

Graduate

Other

Georgia Addiction Counselors Association (GACA) Certification Committee O.7-1-2010


- 10 - Application for CAC Certification

Name of Employer:





Primary Job Duties

WORK EXPERIENCE (Continued):

Past Employer(s)

Name of Employer:





Primary Job Duties

Name of Employer:





Primary Job Duties




JOB DESCRIPTION FORM (Must be typed or printed LEGIBLY)

DO NOT PUT “SEE ATTACHED”

An approved work supervisor is certified or licensed with at least one of the following credentials: NCACI, CACII, NCACII, CADCII,

CAADC, LCSW, LMFT, LPC, RN, APN, Addictionologist, Psychologist, Psychiatrist or other licensed behavioral health providers.

Part I. As part of the Application for Certification, an official job description is required for each position (even with the same

supervisor or agency) listed on your application. It must include all areas below. For example, list separately the percentage of

hours in a typical 40 hour week spent as a counselor/therapist, administrator, aide/attendant, medical personnel (nurse/doctor),

marketing personnel, counselor’s assistant, or other specific job duties.

To be Completed by the Applicant and signed by the Work Supervisor

Date of

Employment

Average

No.

Hours

Worked

Weekly

Brief Specific List of Duties & Responsibilities

Percentage of Time

Spent in Each Area of

Responsibility

EXAMPLE

4-1-2002-

Present

40-45

Recovery Georgia, Inc.

Counselor 1:1 with clients and Leading Patient Groups

75%

Administrative – Record documentation, phone calls, meetings

Marketing – networking, advertising, conference exhibits

15%

10%

Work Supervisor Name (Print) Date Signed

Signature of Work Supervisor Title




TRAINING AND ACADEMIC VERIFICATION FORM (Must be typed or printed LEGIBLY)

(Copy as needed)

TRAINING AND ACADEMIC COURSES: List all training courses and academic/college courses relevant to addiction counselor

certification. [See Certification Guidelines for specifics]. Burden of proof of the validity and relevance of education will be on the

applicant. Education should not be confused with clinical supervision, staff meetings, and case conferences. Applicant must

submit copies of training certificates or other verification of attendance, and if applicable, include a copy of the college transcript

from which those courses are taken that are listed to meet certification criteria; college hours must be converted to contact hours

per the Certification Guidelines formula [1 semester hr = 15 contact/clock hrs; 1 quarter hr = 10 contact/clock hr]

Training Event or College Course

Brief Title/Name

Sponsoring

Organization

Date(s)

Attended

Contact

Hours

GACA

Provider No.

Example: 4/2-5/2017

2017 GACA Spring Conference GACA (General Courses) 21.0 17-4222-01

Example Required Course within a Conference:: 4/3/2017

2017 GACA Spring Conference - Ethics Course Only GACA (Ethics Course) 6.0 17-4222-01

CERTIFICATION BOARD REVIEWER USE ONLY:

Totals for this page, enter all that apply:

GACA NAADAC In Service College

Ethics AIDS Cultural Competency Tele Counseling _______ Too Old (Not Counted)




TRAINING AND ACADEMIC VERIFICATION FORM (Must be typed or printed LEGIBLY)

(Copy as needed)

Training Event or College Course Name Sponsoring

Organization

Date(s)

Attended

Contact

Hours

Provider No.

CERTIFICATION BOARD REVIEWER USE ONLY:

Totals for this page, enter all that apply:

GACA NAADAC In Service College

Ethics AIDS Cultural Competency Tele Counseling ______ Too Old (Not Counted)




WORK SUPERVISOR EVALUATION FORM To be completed by the Applicant’s Immediate Work Supervisor

(Copy as needed for multiple employers and/or positions)

The employee/colleague below is requesting counselor certification with Georgia Addiction Counselors Association (GACA). You have been

identified as the supervisor who is in a position to verify this applicant’s standard of professional work performance and experience. Your

evaluation is an integral part of the application process and will assist GACA in making a fair and accurate decision.

I hereby authorize you to release to GACA the information required by this form.

Applicant's (Printed) Name Last 4 digits of Applicant’s Social Security Number


To Be Completed by the Immediate Work Supervisor

GACA requires the Work Supervisor Evaluation Form to be completed and returned before this applicant's request can be processed. A

separate evaluation must be completed for each position held, even if within the same supervisor or agency. GACA believes that your

observations will have developed a more complete and accurate impression of the competencies and experience of the applicant. Your evaluation

plus information received from other references and data provided by the applicant will be used to determine eligibility for certification. Careful and

truthful reporting will assist GACA in making a fair assessment of this applicant.

AGENCY/WORKPLACE:

AGENCY ADDRESS:

POSITION HELD BY APPLICANT:

GACA is aware that professionals in many fields are associated with agencies which treat the chemically dependent person and many in

individuals in these agencies will have conversation with patients with some therapeutic intent. However, this experience or association does

not necessarily constitute chemical dependency/abuse counseling.

GACA has accepted the following definition of an addiction counselor: An addiction counselor is a person who by virtue of specialized knowledge,

training and experience is uniquely able to inform, motivate, guide, and assist those persons affected by problems related to chemical

dependence/abuse. Additionally, an addiction counselor conducts him/herself in accordance with the GACA Code of Ethics.

An addiction counselor is an individual who has demonstrated the professional competence necessary to perform the following tasks in providing

chemical dependency treatment to clients and significant others in a variety of treatment settings: screening, intake, orientation, assessment,

treatment planning, counseling (individual family, and group), case management, crisis intervention, client education, referral, report and

recordkeeping, and consultation with other professionals in regard to client treatment/services.

An applicant for certification must document paid work experience as a counselor of chemical dependency/abuse clients according to the

above definition. Experience/time when the applicant functioned for example as an aide whose duties may include monitoring

activities or attendance, a nurse/doctor with medical responsibilities, an administrator with supervising/management duties, marketing

personnel employee assistance, referral agent, telephone referral agent, etc. do not constitute toward eligibility for certification.




A. SUPERVISOR’S STATEMENT:

I hereby certify that I have been in a position to observe and have first-hand knowledge of the named applicant’s work at the above

agency/workplace. The number of hours per week the applicant spends functioning as:

1. Counselor/therapist

2. Administrator

3. Aide/attendant

4. Medical Personnel (nurse/doctor)

/week

/week

/week

/week

5. Marketing Personnel

6. Counselor's Assistant

7. Other (describe)

/week

/week

/week

NOTE: If you cannot document any hours the applicant performed as a chemical dependency/abuse counselor under your supervision,

do not continue to complete this form. Proceed to the last page, sign, and return directly to GACA at the address listed.

1. I have supervised this applicant’s work from (Month and Year) to (Month and Year)

2. The caseload for this applicant is (approximate size) clients/patients.

3. Outline the significant strengths and deficiencies of this applicant:

Notable Strengths Notable Deficiencies:

B. PRACTICAL EXPERIENCE EVALUATION: COUNSELOR SKILL GROUPS In this section you are asked to evaluate the competency of the applicant as a

chemical dependency /abuse counselor in the 8 Counselor Skill Groups.

CIRCLE THE HIGHEST NUMBER

WHICH BEST DESCRIBES THE

APPLICANT’S PERFORMANCE

Does not

Perform

this Task

Treatment Admission (Screening, Intake and Orientation)

1

2

3

4

5

0

Clinical Assessment

1

2

3

4

5

0

Ongoing Treatment Planning

1

2

3

4

5

0

Counseling Services (Individual, Group, Family, Crisis Intervention, Client Education)

1

2

3

4

5

0

Case Management

1

2

3

4

5

0

Documentation

1

2

3

4

5

0

Discharge and Continuing Care

1

2

3

4

5

0

Legal, Ethical, and Professional Growth Issues 1 2 3 4 5 0




C. APPLICANT EMPLOYMENT HISTORY

Listed below are 7 basic grounds on which certification may be refused or revoked. Please read carefully.

To your knowledge, has the applicant been involved in any of the following: (The Certification Board will consider very carefully

any comments made in their decision to certify or not to certify.).

YES

NO

Employment of fraud or deception in applying for certification or in passing the examination provided

for in this procedure

Conviction of felony (Satisfactory resolution of said felony will be taken under consideration)

Practice of addiction counseling under a false or assumed name or credentials, or the impersonation of

another counselor of a like or different name

Habitual abuse of any mood-altering chemical substance not prescribed and taken under the direct

supervision of a qualified physician to such an extent as to interfere consistently with the competent

performance of his/her duties

Providing those health care services covered by licensure for which the counselor is not licensed

Gross, flagrant, or repetitive negligence or wrongful actions in the performance of his/her duties

Failure to adhere to the GACA Code of Ethics

Comments:

Print Name Credentials

Signature Telephone - include area code and/or extension:

( )

Job Title

Work Supervisor: Please return this Work Supervisor Evaluation Form directly to GACA as soon as completed:

Georgia Addiction Counselors Association, 4015 South Cobb Drive, Suite 160, Smyrna, Georgia 30080




Certified Clinical Supervisor

Supervised Practical Experience Form (Copy as needed for multiple supervisors)

The applicant named below is requesting counselor certification with the Georgia Addiction Counselors Association (GACA). You

have been identified as the individual who is in a position to verify the supervised practical experience. This report will be

combined with other documents and assessments and is an integral part of the application process. Your cooperation will assist

GACA in making a fair and accurate decision.

I hereby authorize you to release to GACA the information required by this form.

Applicant’s (Printed) Name Last 4 digits of Applicant’s Social Security Number


…………….………………………………………………………………

To Be Completed By the GACA Certified Clinical Supervisor (CCS)

In order to assist you with the SPE form, GACA provides the following guidelines:

Supervised Practical Experience (SPE) is supervision which teaches chemical dependency/abuse counseling. This experience may

be academic, as in a practicum, or may be a part of eligible work experience. The supervision must include one-to-one and group.

The fact that an applicant worked under administrative supervision does not in itself satisfy this requirement. The reporting

function is to distinguish from the learning function. Thus, attendance at staff meetings to report on client progress may not be

considered supervision. The supervision should include activities designed to provide education in specific skill groups and be

monitored by a supervisor who provides timely positive and negative feedback to assist in the development of knowledge and

competence.

In this section, indicate the amount of time and type of supervision – not time spent performing the 8 counselor skill groups. Do

not sign this form if it reflects supervised time given by another person or at another agency. Once completed, mail this form

directly to the GACA office.

N OTE: Clinical supervision requirements are further defined to require that 25% of clinical supervision by a CCS be individual

(one-on-one) supervision. Thus, a minimum of 24 of the 96 required CCS hours for CACI and a minimum of 36 of the144 required

CCS hours for CACII must be individual supervision. Further, a minimum of two (2) hours of individual supervision must be

provided in each of the 8 Counselor Skill Groups. COUNSELOR SKILL GROUP

Type of Supervision Total hours

per skill

group

Individual

hours

Group

Hours

Treatment Admission (Screening, Intake and Orientation) - The interaction with the client to determine

suitability for alcoholism and/or drug abuse treatment. Information necessary for admission, appropriate assessment

and appropriate treatment is collected; the client is oriented to the counseling process. Rules and expectations including

financial responsibilities.




Clinical Assessment - To synthesize and interpret the data collected during the treatment admission in order to

determine the client’s immediate problems, internal/external resources that may facilitate or inhibit the treatment

process. This assessment forms the basis for the treatment goals and program established for the client.

Ongoing Treatment Planning - A specific, individualized treatment plan that addresses the therapeutic needs of the

client and places him/her in the appropriate placement on the continuum of care. The client’s strengths and weaknesses

must be considered in setting priorities for long and short term goals and treatment. This plan must ultimately be

formulated with the client.

Counseling Services (Individual, Group, Family, Crisis Intervention, Client Education) - The interactive

process providing assistance to a client to help him/her change and maintain attitudes, beliefs and behaviors that are

more constructive. The counselor must determine the most appropriate type of assistance and the counseling

intervention to facilitate the change in behaviors, attitudes and beliefs. Counseling services included individual, family,

group and crisis intervention counseling.

Case Management - This encompasses case consultation and interfacing with other agencies and professionals to

provide the services needed by the client in order to achieve the treatment goals. Consultation and case review by a

clinical supervisor is a vital component of managing the counseling process and providing quality care.

Documentation - This encompasses maintaining and recording the results of the treatment process accurately,

descriptively and in a timely fashion. The legal document describes treatment including forms, releases, and consent

forms and records.

Discharge and Continuing Care - Discharge involves the reinforcement of the changed attitudes, beliefs and

behaviors, assessment that there are no other pressing needs, following up on the client’s status, making appropriate

referrals for continuing services if necessary, and assessing the adequacy of support systems. Information on relapse

prevention, continuation of self-help programs and other support mechanisms should be provided to the client as a part

of the termination process.

Legal, Ethical, and Professional Growth Issues - This skill group includes the federal and state legislation

governing the counselor/client relationship, adherence to the Code of Ethics that addiction counselors are expected to

follow in their practice and areas of continuing self-education and growth. The dynamic nature of the therapeutic

process demands continual self-evaluation, monitoring and self-awareness.

TOTAL SUPERVISED PRACTICAL EXPERIENCE HOURS CAC I and CAC II Required Minimum: 55 Individual and 165 group supervision hours

CERTIFIED CLINICAL SUPERVISOR’S AFFIDAVIT

Supervision listed above is from to (Month and Year) to (Month and Year)

I, , avow that to the best of my professional judgment

meets all the requirements for the (circle one) _CAC I or CAC II level

credential requested and, furthermore, is prepared and capable of completing the National Certification (Written)

Examination for Addiction Counselors with a passing score.

Certified Clinical Supervisor’s (CCS) Signature Date Signed

Printed Name of CCS Daytime Phone Number

CCS Certificate Number CCS Expiration Date

Return this form directly to GACA as soon as complete to: Georgia Addiction Counselors Association,

4015 South Cobb Drive, Suite 160, Smyrna, GA 30080

certification application submission instructions...2018/03/25 · individual who holds a certified...

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